Screening for osteoporosis
BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7218.1148 (Published 30 October 1999) Cite this as: BMJ 1999;319:1148
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Dear Sir,
Professor Fogelman failed to address two important issues on the above
subject. The first related to the prevention and management of
osteoporosis (OP) and the second the screening and management of a high
risk group of patients namely young women who developed ovarian
dysfunction as a result of adjuvant systemic therapy.
No mention was made on the role of exercise in the prevention of OP
and high impact exercise to reduced osteoporotic fractures. Exercise is
highly recommended for all post menopausal women. Several studies have
established increasing bone mineral density (BMD) and reduced osteoporotic
fracture when this is practiced (1&2). Also left out is the role of
Raloxifene a Selective Estrogen receptor Modulator (SERM)i in the
treatment of OP. This new compound has an estrogenic effect on bone,
serum lipid, and blood clotting and antiestrogenic effect on the breast
and endometrium. It is an effective treatment for patients with OP
(3&4).
The second point is the screening and management of a selected high
risk group of patients namely young breast cancer patients who developed
ovarian dysfunction as a result of adjuvant systemic chemotherapy or
Tamoxifen. Menopausal symptoms are quite pronounced in this group of
patients due to the sudden cessation of ovarian function.
While Bisphosphanate has been used successfully to treat OP (5), this will
not help other sequllae of the menopause e.g. Vasomotor, psychological,
urogenital atrophy and the effect on the cardiovascular system. Hormone
replacement therapy has been used in such patients but this increased
breast cancer related event (6). HRT is the only treatment that will deal
with all menopausal symptoms but in general the patient and to some extent
clinicians are usually reluctant to use this in women with history of
breast cancer. A risk-benefit analysis should be discussed with the
patient and a learned joint decision should be reached.
1. Henderson NK et.al. The roles of exercise and fall risk reduction
in the prevention of osteoporosis. Endocrinology and Metabolism Clinics of
North America. 27(2):369-87,1998
2. Heinonen A et.al. Randomised controlled trial of effect of high-
impact exercise on selected risk factors for osteoporotic fractures.
Lancet. 348(9038):1326:7,1996
3. Cummings SR et.al. The effect of raloxifene on risk of breast
cancer in postmenopausal women.:results from the MORE randomised trial.
Multiple Outcome of Raloxifene Evaluation.JAMA.281(23):2189-97.1999
4. Bryant HU. et.al. An estrogen receptor basis for rasloxifene
action on bone. Journal of steroid biochemistry and molecular biology.69(1
-6):37-44,1999
5. Pawles TJ .et.al. Oral chlodronate and reduction in loss of bone
mineral density in women with operable primary breast cancer. Journal of
national cancer institute,90,704-708,1998
6. Vassilopoulou-Sellin R. et.al. Estrogen replacement therapy after
localized breast cancer: clinical outcome of 319 women followed
prospectively. Journal of Clinical Oncology,17(5) 1482-91,1999
Competing interests: No competing interests
Dear Sir,
I am very astonished to find a editorial about fracture risk and
osteoporosis tat does not discuss fall risk status. More than 90 % of hip
fractures result from a fall. A fall from standing height generates a
force of 3500 to 10000 Newton, enough to break the hip of an
individual without osteoporosis. The BMD values of fallers with and
without osteoporosis overlap to a great extent.
It is the combination of propensity to fall and reduced bone strength which
leads to the steep increase of hip fractures in the aged. We have to
discuss the instruments which enable us to perform risk stratification of fall
risk status.
It is not in the interest of our patients to neglect the conditions and
mechanisms of falling. I think we should always discuss bone strength and
falls together, especially because they are linked through muscle
function. Wolff`s law: form follows function! Bone mass is directly
dependent on the forces that are applied to it by the muscles.
Sincerely M. Runge
Competing interests: No competing interests
In this editorial Fogelman said that "the situation (about the
screening for osteoporosis) is rapidly changing because of the availability
of ultrasound systems....". He tell us that ultrasound systems could
be used in the future as a prescreening test for dual x ray
absorbiometry.
Recently, we conducted a comparative study between ultrasound bone
densitometry at phalanxes (DBM-sonic-1200) with dual energy x-ray absorptiometry at lumbar spine and hip (LUNAR). One hundred forty women who
came to our office and had a dual energy X-ray absorptiometry measure
(LUNAR ®) in the last year were studied by ultrasound densitometry at
proximal phalanxes (DBM-sonic-1200®). The sound velocity (SOS) was
compared with bone mineral density (BMD) at the lumbar spine, femoral neck,
trochanter region and Waards triangle. The sensitivity and specificity
were established at differents SOS cut points. In this study we found a
positive correlation between SOS and BMD: at the spine it was 0.40(p<_0.001 at="at" the="the" femoral="femoral" neck="neck" _0.35p0.001="_0.35p0.001" waards="waards" triangle="triangle" _0.37p0.001="_0.37p0.001" and="and" in="in" trochanteric="trochanteric" region="region" _0.18p0.001.="_0.18p0.001." patients="patients" aged="aged"/>50 years, with BMI>26 and post-menopausal women showed
better correlations. By defining osteoporosis by a DEXA measure below
-2.5s ( T-score) in any area (lumbar spine, femoral neck, Waards
triangle, and trochanteric region) and using a cut point SOS=1960 we
obtained a test with a sensitivity of 90.7%, specificity of 45.1%,
positive predictive value of 58.2% and negative predictive value of 85.2%.
With this results we concluded that ultrasound bone densitometry at
proximal phalanxes shows only moderate correlations with BMD measured
by DEXA at lumbar spine, femoral neck and Waards triangle. The ultrasound
bone densitometry at proximal phalanxes is not a valid tool for screening in
osteoporosis.
Competing interests: No competing interests
Screening for Osteoporosis
Prof. Fogelman notes that although the Royal College of Physicians
have recently concluded that there is no universally accepted policy for
screening for osteoporosis, the situation is rapidly changing because of
the availability of ultrasound systems for assessing the skeleton (1). He
also notes the attractions of this method in terms of portability and
cost. The ability of this investigation to predict fracture as well as
dual x-ray absorptiometry (DXA) in elderly women is an added attraction
(2,3).
While recognising the limitations of and concerns about ultrasound
measurements, it can represent a useful adjunct in assessing those at
risk. We recently completed our first year's experience in using
quantitative ultrasound bone measurements (QUA) as part of a shared-care
approach to osteoporosis between hospital and general practitioners. We
assessed 298 patients of whom 124 were 65 years or older. All requests for
QUA were accompanied by a proforma highlighting the individual's risk
factors for osteoporosis as well as the reason for making the request. The
results were interpreted by a physician with a special interest in
osteoporosis who reported the scan as normal, osteopoenic or osteoporotic
depending on the ultrasound T score. Our advice was tailored to the
individual patient's risk profile as well as their age. The mean age of
the older age group was 72.8 years (range 65-90 years). The commonest
reasons for referral in this group was back pain, history of low-trauma
fracture and suspicion of osteoporosis on x-ray. Most patients with back
pain had additional risk factors. The results of the scans indicated that
38% of patients were osteoporotic. Taking their backgrounds into account,
34% were advised to commence anti-resorptive therapy and a further 10%
Ca/Vitamin D with most proceeding to treatment. Six-month follow-up
indicated good compliance. Because of doubts about the validity of this
method in a younger age group, the advice given regarding this group was
more cautious. Further evaluation with DXA scans were advised in specific
cases.
We agree that screening those who may already be obviously eligible
for treatment is not useful. However, as an adjunct in assessing at-risk
patients, QUA can help build a clearer picture of an individual's risk
profile and determine a treatment strategy. In the current U.K. climate of
limited availability of DXA scanning, QUA is an attractive tool.
References
1. Fogelman I. Screening for Osteoporosis. BMJ 1999; 319: 1148-1149
2. Hans D et al. Ultrasonographic heel measurements to predict
hip fracture in elderly women; the EPIDOS prospective study. Lancet
1996;Vol. 348: 511-514
3. Bauer D et al. Broadband ultrasound attenuation predicts
fractures strongly and independently of densitometry in older women. Arch
Intern Med 1997; Vol. 157:629-634
Colm Henry
Specialist Registrar
Department of Medicine of the Elderly,
Edinburgh Royal Infirmary,
1 Lauriston Place,
Edinburgh EH3 9HA
D L Farquhar
Consultant in Medicine of the Elderly
Department of Medicine of the Elderly,
St. John's Hospital at Howden,
Livingston
EH54 6PP
Scotland
Competing interests: No competing interests